Natalie Rodriguez is a clinical nurse on a 65-bed oncology unit in a large teaching hospital in Phoenix, Arizona. She is a new graduate from a baccalaureate nursing program and strives to provide the best possible care to each of her clients. Nurse Rodriguez checks in on a 90-year-old patient, Mrs. Marting, who has pancreatic cancer. She has only one granddaughter, Allie, to come visit and stay with her for long hours each day, and the two are very close. Mrs. Marting has said she does not want any resuscitation measures, but when Nurse Rodriguez offers her DNR forms to sign, she waves them away. “I’m too sick right now, dear,” she says. “Let me deal with paperwork some other time.” In the meantime, Nurse Rodriguez has other patients she must attend to, but even as she tries to perform other tasks, Mrs. Marting’s wishes are on her mind. However, before she can return to Mrs. Marting and Allie, Dr. Daly arrives on the unit with a list of demands. Dr. Daly has a reputation for wanting “what I want when I want it,” and he asks Nurse Rodriguez to complete a laundry list of tasks that are not particularly patient-centered. She is restocking a supply cabinet, at his request, when Allie calls for help. Dr. Daly gets to Mrs. Marting’s room first and by the time Nurse Rodriguez arrives, Allie is begging the doctor to “do whatever it takes to save my grandma!” Mrs. Marting has undergone cardiac arrest. Nurse Rodriguez explains Mrs. Marting’s wishes, but Allie says, “I know, but I don’t care now! Just save her!” and Dr. Daly starts resuscitation.

1. Nurse Rodriguez is devastated by Dr. Daly’s choice and wonders what she could have done to stop resuscitation, which has broken one of Mrs. Marting’s ribs. “I don’t ever want to see that happen to one of my patients if I have anything to say about it,” she says. What kind of stress is Nurse Rodriguez experiencing, and which category of obstacle created it?
2. Nurse Rodriguez has said that she does not want that to happen to any of her patients again, if she can do anything to prevent it. What stage or phase of the “change process” outlined by the AACN is she most strongly associating with, and what, if anything, should she do first before acting on it?

Why are good data essential to sound decision making, both clinical and business related

You have a fellow student with a history of stress incontinence. While sitting in the classroom someone states a funny joke and they start laughing so hard they “pee their pants”? What should be done to help this student? What is stress incontinence, the symptoms associated with it and who is at risk for having it? How do we treat this disorder?

Scenario

M.D. is a 50-year-old woman whose routine mammogram showed a 2.3- × 4.5-cm lobulated mass at the 3 o’clock position in her left breast. M.D. underwent a stereotactic needle biopsy and was diagnosed with invasive ductal carcinoma, estrogen and progesterone receptor positive, HER-2 negative. The staging workup was negative for distant metastasis. Her final staging was stage IIB. She had a modified radical mastectomy with axillary lymph node dissection. The sentinel lymph node and 4 of 16 lymph nodes were positive for tumor cells. An implanted port was placed during surgery.

1. What are the risk factors for breast cancer?

2. Describe the biopsy technique used to diagnose M.D.’s cancer.

3. Breast cancer is classified as noninvasive or invasive. Compare these terms.

4. Discuss the implications of a positive sentinel node.

5. What factors affect prognosis and treatment for breast cancer?

6. Is she a candidate for tamoxifen therapy? Explain your reasoning.

7. Surgical intervention is the primary treatment for breast cancer. Describe the surgical procedure that M.D. had.

8. Describe M.D.’s risk for lymphedema.

9. What actions will you teach M.D. to reduce her risk for developing lymphedema?

CASE STUDY PROGRESS

Eight weeks after surgery, M.D. is now beginning a prescribed chemotherapy regimen of 6 cycles of CAF (cyclophosphamide, doxorubicin, and fluorouracil).

10. M.D. asks you why she has to have chemotherapy with so many drugs if the surgeon removed all the cancer. How would you respond?

11. Name the common side effects experienced by patients receiving a chemotherapy regimen.

12. What information would you want to review with M.D. about the signs and symptoms of infection and when to seek treatment?

13. M.D. is ordered doxorubicin at 75 mg/m². Her height is 5 feet, 7 inches (170 cm), and her weight is 155 pounds. Calculate the dose she will receive.

CASE STUDY PROGRESS

M.D. has now completed three cycles of chemotherpy, with her last treatment 12 days ago. She comes to the emergency department with a 1-day history of fever, chills, and shortness of breath. On arrival, she is slightly confused and agitated. Vital signs are 100/60, 119, 26, 103.6° F (39.8° C), Spo₂ 86% on room air. The chest x-ray examination shows diffuse infiltrates in the left lower lung consistent with pneumonia. Her basic metabolic panel is within normal limits, except the blood urea nitrogen (BUN) 28 mg/dL (10.0 mmol/L) and creatinine 1.6 mg/dL (141 mcmol/L).

Chart View

Complete Blood Count

16. Interpret M.D.’s laboratory results and explain the reason for any abnormal results.

17. M.D.’s absolute neutrophil count (ANC) is calculated as less than 500/mm3, describe the significance of this value.

18. What is your nursing priority at this time?

19. What is the single most important nursing intervention for a patient with an ANC below 500/mm³?

20. When is neutropenia most likely to occur in a person receiving chemotherapy?

21. What type of isolation do you need to initiate for M.D.? Outline the guidelines for maintaining this type of isolation.

22. What collaborative care interventions do you expect for M.D.?

23. What immediate nursing interventions do you need to take?

24. What actions do you need to take because M.D. had a left axillary lymph node dissection and why?

25. The provider orders a 500-mL normal saline bolus now, with orders to infuse over 2 hours. You decide to use M.D.’s implanted port for IV access. After you access the port and connect the fluid, the infusion pump alarms that the line is occluded. What will you do?

The Patient’s Experience: What Were They Thinking? – Case for Chapter 4

Sheila K. McGinnis

Thanksgiving weekend. Tanya Martinez is looking forward to a busy holiday weekend entertaining her extended family. Tanya, 29, is a busy stay-at-home mom. She has a degree in Business Administration and recently worked in marketing for a major insurance company in the city. Married nearly 8 years ago, Tanya and her husband Alex, 29, have two children. Tanya quit working several years ago to raise their two children, 4-year-old Randy and 2-year-old Samantha. The Martinezes, a multiracial couple, lived in a large city in the Northwest, where Alex works as a skilled construction carpenter on high-rise commercial building projects.

Tanya, Alex, and the kids celebrated the holiday with Tanya’s mom Deidra, a city engineer; dad Michael, a college professor; her brother, a computer engineer; and her sister-in-law, a nurse practitioner. On Friday, Tanya felt some nausea and intestinal discomfort, which she assumed was due to the Thanksgiving festivities. While Tanya was typically active and athletic, she had to skip her usual long-distance run. By Saturday, her condition had quickly worsened. She was weak, vomiting with periodic abdominal pain, and using cold compresses for a high fever.

With Tanya running a 103^o fever Sunday, Alex stayed home with Randy and Samantha, while her parents Deidra and Michael took her to Urgent Care at a nearby full-service medical center. There she was quickly sent to the Emergency Department of the 400+ bed, Level 2 Trauma Center. Various lab tests and a CT scan showed an elevated white blood cell count, but no conclusive findings regarding her non-specific intestinal discomfort. So, after rounds of antibiotics and fluids for dehydration, Tanya was sent home without any prescriptions or further instructions.

Tanya’s condition did not improve by Tuesday, and she was still experiencing a high fever plus nausea, bloating, and abdominal pain. The family brought Tanya back to Urgent Care, where she was sent to the Emergency Department again, and then referred to the main hospital for observation care. Observation care is a hospital outpatient category (even though patients stay overnight). It is controversial because it blurs the lines between outpatient and inpatient care, which often increases the patient’s financial liability (due to larger co-pays). It can also compromise clinical care delivery due to poorer coordination of care during observation stays (Hagland, 2018; Society of Hospital Medicine, 2017).

In the observation care ward, Tanya was seen by several hospitalists who each interacted with her for different purposes and with different questions. They conducted a variety of additional blood draws and lab tests to assess intestinal illnesses such as Crohn’s disease, inflammatory bowel conditions, or possible intestinal blockage. While observation care is intended to take 24 hours, or 48 hours maximum, in practice it sometimes exceeds 48 hours (Society of Hospital Medicine, 2017). Tanya ended up in observation care for 5 days.

Observation ward rooms are shared, and during Tanya’s stay, three different female roommates entered observation care and were admitted to inpatient care shortly thereafter. Tanya’s first roommate did not permit Tanya’s husband Alex to stay overnight with Tanya, so her mother stayed with her each night. Alex, their children, and family were frequent visitors during the 5 days.

One evening when both parents Deidra and Michael were visiting Tanya, they noted two uniformed city police officers in the corridor talking to the in-charge nurse. The pair of officers soon entered Tanya’s room unannounced saying “We have to check your belongings,” without offering any explanation. Tanya and her parents complied but were unclear about what was happening. When one officer asked, “Does she have a history of drug abuse?” Deidra exploded, saying “What are you doing here? Leave right now!” The officer explained “We’ve had calls and a report there have been a lot of visitors and possible illegal drug activities here.” Next, the in-charge nurse burst into the room stating, “It’s a mistake, it’s not this room, it’s another room!” The officers were quickly redirected to search the nearby room occupied by a well-tattooed white male.

Frustrated by days with no clear diagnosis or treatment plan and angered by the allegation his daughter was using drugs, Michael demanded “I want to see the nursing supervisor now or we are leaving this hospital and will sue you!” When the RN supervisor arrived, Michael confronted him “Why did you call the cops on my daughter?” The supervisor wanted to check on what happened and scheduled a meeting for the next day after tempers had cooled.

During a tense meeting with the RN supervisor the next day, her parents sought to transfer Tanya to a different hospital and leave “Against Medical Advice” (AMA). Informed that insurance might not cover an AMA transfer, and that another hospital might not accept an AMA, they “felt like hostages, with no options.” Unwilling to take the risk, the parents compromised that the hospital could transfer Tanya to the medical floor on in-patient status with a private room.

Michael and Deidra also confronted the floor nurses, asking “Why did you send the police to Tanya’s room?” The nurses explained that “somebody had called the cops,” leaving the nurses to guess which patient it might be. A junior nurse admitted she had pointed the police towards Tanya’s room. Even Tanya’s observation ward roommate, who was present when the police arrived, said their treatment from the nurses and officers was inappropriate. The hospital’s security chief apologized and said he “would look into” the incident with the police.

Tanya spent another week as an inpatient on the medical floor. At the time of transfer to inpatient status, she was generally stable, though very weak, and showed few signs of improvement. She was still nauseous, with abdominal distention and cramping, and little bowel activity. The family hoped Tanya’s attentive new physician, Dr. Johnson, would finally get a clear diagnosis and treatment plan. Dr. Johnson arranged for endoscopy and requested other consults, though staff resisted performing a second CT scan (after two previous ones in the ED), saying “she should get better.” Finally, 4 days later, before going off rotation, Dr. Johnson’s written medical report called for a surgical consultation, stipulating that if the hospital could not provide answers and appropriate treatment the patient would need to be transferred to University Hospitals for additional evaluation and care.

At last the third CT scan clearly showed an intestinal ileus—a potentially dangerous stoppage of the normal intestinal contractions that move food through the intestines. While an ileus is commonly a complication of abdominal surgery, Tanya had no history of surgery or medical conditions that lead to an ileus, and prior to her sudden hospitalization had been very healthy and fit. After surgeons drained accumulated fluids and matter from her lower abdomen, they put her on antibiotics, and released her from hospital the next day—after 2 weeks in the hospital. Tanya gradually recovered at home, though it took several months to regain her strength and eventually return to her active lifestyle.

Deidra and Michael filed a complaint on Tanya’s behalf shortly after she was released from hospital. They identified the following substandard practices:

• ■   Abusive encounter: Patient was accused by uniformed police of using drugs without reasonable cause. This incident also raised the question of whether Tanya and her husband came under suspicion because Alex is of Latino/Native American descent.

• ■   Negligence that compromised quality of care: Patient was assigned to observation care for 5 days without clear diagnosis and treatment; patient was admitted on in-patient basis for 5 days and staff resisted taking further action to refine the diagnosis and treat appropriately. The resulting delayed confirmation of an ileus further weakened Tanya and prolonged her time to full recovery months later.

• ■   Observation Notice Requirement: Patient was assigned to and maintained on observation status without sufficient diagnostic efforts, and without explanation of its clinical and financial implications.

The hospital completed its internal review without interviewing Tanya, her family members, or her roommate. While acknowledging the grievance, the hospital’s report concluded Tanya’s care was appropriate.

QUESTIONS

1. What automatic thinking, cognitive biases, and stereotypes may be affecting how each of the actors sees this situation? Include as many as you can think of.

2. What stereotypes or biases might hospital staff hold about a potential drug user?

Case Scenario: Mr. Wu’s Story (adapted from Burkhardt, Nathaniel & Walton, 2018, p. 118)

Read the following case scenario, then apply your understanding of values clarification by answering the questions in the graded Week 4 Discussion Board forum called Personal Values Clarification.

82-year-old Mr. Wu has been hospitalized with a stroke that has left him severely incapacitated - he can transfer to a wheelchair with assistance, but needs help for toileting, feeding, bathing and dressing. He has expressive aphasia so it is difficult for him to speak clearly and it is uncertain how much he understands in a conversation. Prior to his stroke, the widowed Mr. Wu lived with his daughter Sophia and her family (husband Marc and their three small children). He was a supportive and helpful member of the family, providing occasional child-care and helping with small household tasks.

The physician feels Mr. Wu is ready for discharge and is being pressured by the hospital administration to free up bed-space. The physician has suggested that Mr. Wu go to a nursing home and she has asked the nurses to try to talk the family into it.

Sophia has told you on a previous occasion that she feels she should take him home with her because her faith and culture say she should provide care for her parents. She is the eldest in the family and her siblings live far away, so she feels it is her duty to care for their father. But the Wu family house is small and Mr. Wu can no longer manage stairs, so they would need to add a bathroom to the ground floor. Sophia also has concerns because she works full time. Sophia has considered quitting her job in order to care for her father, but the family needs her income because her husband’s work is seasonal. They cannot afford to hire a caregiver during the day when Sophia is at work.

You overhear Sophia and her husband in the hallway outside Mr. Wu’s room. Her husband is speaking very firmly: “I just don’t see how we could possibly do it. It is too much for you to take on with all the other things you do. And I wouldn’t know how to take care of him. Looking after the old folks was not something we did in my family.”

Sophia replies, “I don’t know what to say. I just want to do what’s best for Dad. When he came to live with us I promised him – we promised him - that he’d always have a place with us.”

Marc replies, “But he doesn’t remember that promise. He doesn’t remember anything.”

The Discussion Board questions about this scenario are as follows:

1. What are your own values in this situation? (Imagine this were your own family.)
2. How might your own values affect your actions as a nurse?
3. What might the patient’s and family’s values be in this situation?
4. Is there a values conflict here? If so, how might you begin to resolve this conflict?

can you explain the etiology of pre-renal failure?

also is it pre-renal or post renal failure if

- urine output has been less than 100 mls per day for the last 3 days since the hypotensive episode.

- His Creatinine is 3.5 and BUN is 39

- has been diagnosed with acute renal failure caused by acute tubular necrosis.

also, can you explain why it is or is not pre-renal?

thank you!

Identify your motivation for eating

Focus on your nutritional requirements

Know your food triggers, such as for pinpointing allergies

Keep track of calories for weight loss/gain goals

Eat more healthily

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Breakfast







Snack







Lunch







Snack







Dinner







Snack







Water (glasses/oz. per day)







Soda/Milk/Juice/Alcohol (Wine, Beer)







Exercise (minutes per

A 5-year-old child who had been receiving dialysis treatments has undergone renal transplant and will now be taking prednisone. The parents are hopeful the child's development and overall health will normalize. The nurse should inform the parents that taking prednisone can result in some similar adverse effects as living with chronic kidney disease (CKD). Which effects should the nurse include? Select all that apply.

When explaining the role of the proximal tubule in terms of medication administration, the nursing instructor will emphasize that which medications are bound to plasma proteins and require the proximal tubule secretion of exogenous organic compounds to help with filtration? Select all that apply.

You are caring for a client who is being treated for pneumonia. You suspects the client has developed pleuritis. Which assessment findings support the your suspicion of pleuritis? Select all that apply.

A client diagnosed with a cerebrovascular accident (CVA) 5 months prior is now experiencing episodes of urinary incontinence. The client asks, "Why is this happening?" Which statement best captures the facts that would underlie the answer to this question?

You are in the respiratory unit of a hospital is providing care for a client with end-stage lung disease. Consequently, measurement of the client's arterial blood gases indicates increased PCO₂. Which associated consequence would the nurse anticipate?

You are caring for a client in emergent fluid overload requiring rapid diuresis. Which diuretic should the nurse be prepared to administer?

You are planning the care for a client with acute kidney injury (AKI). What should the nurse prioritize in the client's plan of care? Select all that apply.

Which individual is at the highest risk of developing a urinary tract infection (UTI)?

A dialysis technician is reviewing a textbook on kidney function. The technician would recognize which statements as characteristic of healthy kidneys? Select all that apply.

What does WBC test in the urinay analysis test for, if my patient has atrial fibrillation and kidney diease does it relate to that?

What is the bacteria test in the urinary anaylsis testing for, if my patient has atrial fibrillation and kidney diease does it relate to that?

Rationale for assessing the skin, hair, and Nails.

Rationale for assessing the peripheral vascular & lymphatic

How can a new or experienced teacher, plan ways to include physical activities in their program on a daily basis?

What kinds of physical activities do children seem to enjoy?

How can a teacher create opportunities for them to build on their interest and pleasure in such movements?

History of present illness: This 72-year-old female presented to the ENT clinic complaining of her current epistaxis for 7 days prior to admission. The bleeding usually occurred from the right nostril. She had no prior history of epistaxis and denied any rhinorrhea. congestion, or anemia. On admission, she also complained of weakness. Four days prior to admission, her hematocrit level was 35, and the night before her admission, her hematocrit level was 29 when measured at an outside hospital. Her past medical history was significant for rheumatoid arthritis. Her past surgical history included status post bilateral knee replacement and right hip replacement. Medications at the time of admission included prednisone, 2 mg PO b.i.d.. and aspirin, six to eight per day for the past several months. Allergies: none.

Physical examination: On physical examination at the time of her admission, she was afebrile. Her blood pressure was 114/70, and her pulse was 92. Examination of the head and neck was significant for nasal cavities, which were without lesions and without PhYSical bleeding Sites. the remainder of the head and neck examination was within normal limits. Her neck was normal with no jugular venous distention. The lungs were clear. The heart rate was regular, and heart rhythm was Without murmurs. the abdomen was soft without masses, and the extremities had no bruises, cyanosis, or edema.
Laboratory data and hospital course: The patient was admitted, and a right anterior nasal pack was placed. Serial hematocrit levels were also obtained. The night of her first day of admission, she required replacement of an anterior pack because of refractory bleeding. The day following her admission, she underwent transfusion with 2 units of packed red blood cells for a hemoglobin level of 8.
0n the second day of her admission, bleeding was noted around the anterior pack. For this reason, she was taken to the treatment room, where a posterior nasophafyngeal pack and a new anterior pack were placed. She was then transferred to the special care unit and monitored on the cardiac monitor and with pluse oximetry. The posterior pack was left in place for 2 days. At this time, a repeat episode of bleeding showed that her bleeding time had normalized from its previous elevated level. She wasobserved overnight for 1 day without a pack in place. The patient did well during this observation period without any further bleeding.
When it was confirmed that the patient had no further bleeding for 48 hours after pack removal and the hematocrit level was stable, she was discharged to home. She was instructed to follow-up with her private PhySician. She was also instructed to refrain from taking aspirin and to use Disalcid 750 mg t.i.d., instead, for her arthritic pain. She was also placed on iron supplements 300 mg three times a day and told to continue using saline and Prenaris nasal drops.
Final diagnosis: Epistaxis.
Additional diagnosis: Rheumatoid arthritis.
1 Principal diagnosis:
2. Other diagnoses:
3. Principal procedure:
4. Other procedures:
5. Conditions to clarify with physician:

Need Help ICD-10-CM codes with POA indicator aassignment when required, ICD-10-PCS codes.